Provider Demographics
NPI:1700124666
Name:RANDOLPH WALTERS & ASSOCIATES, LLC
Entity Type:Organization
Organization Name:RANDOLPH WALTERS & ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER/DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDOLPH
Authorized Official - Middle Name:WINDELL
Authorized Official - Last Name:WALTERS
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, LPC
Authorized Official - Phone:610-639-1729
Mailing Address - Street 1:1989 N 63RD ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19151-2607
Mailing Address - Country:US
Mailing Address - Phone:610-639-1729
Mailing Address - Fax:215-878-8998
Practice Address - Street 1:1989 N 63RD ST
Practice Address - Street 2:SUITE 200
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19151-2607
Practice Address - Country:US
Practice Address - Phone:610-639-1729
Practice Address - Fax:215-878-8998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-27
Last Update Date:2013-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC002890251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health